American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 9-1-09

Highlights

  • Retail clinics reaching more of the U.S., providing some treatments more cheaply
  • IDSA releases updated immunization guidelines

Test yourself

  • MKSAP Quiz: nasal mucosa with a profuse watery discharge

Women's health

  • Symptoms can be early indication of ovarian cancer

Medical imaging

  • CT and nuclear scans major source of radiation exposure

Cardiology

  • Combination therapy seems to offer no benefit over high-dose statins in high-risk patients
  • Paper summarizes latest evidence on antiplatelets and antithrombotics for ACS

FDA update

From ACP Internist

  • The next issue of ACP Internist is online and in your mailbox
  • Your Thoughts Exactly: town hall meetings on health reform

Cartoon caption contest

Editorial note: ACP InternistWeekly will not be published next week due to the Labor Day holiday.

Physician editor: Darren Taichman, ACP Member


Highlights

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Retail clinics reaching more of the U.S., providing some treatments more cheaply

Two studies in the Sept. 1 Annals of Internal Medicine describe the expanding reach of retail clinics in the U.S., reporting that they are conveniently located for people, particularly in urban areas, and provide comparable, lower-cost care for three common conditions than doctors' offices or emergency departments.

The first study found that 10% of the population lives within a 5-minute drive of a retail clinic and about a third live within a 10-minute drive, and even more do so in urban areas.

About 1,000 retail clinics, defined as no-appointment clinics located in retail stores that are often open nights and weekends, now operate across the country. They offer a limited range of services, such as immunizations and minor acute care. (Click on the map for a larger version.)

The second study examined claims filed by enrollees in HealthPartners, one of Minnesota's largest health plans, from 2005 to 2006.

Researchers identified 2,100 episodes first treated in retail clinics (700 each of otitis media, pharyngitis, and urinary tract infection) and matched them on the basis of condition, age, sex, comorbidity, and income to episodes first treated at doctors' offices (6,211), urgent care centers (5,880), and emergency departments (979).

AnnalsOverall costs of care at retail clinics were substantially lower than those of matched episodes ($110 vs. $166, $156, and $570, respectively; P<0.001). The primary reason was lower reimbursement for evaluation and management in retail clinics ($66) compared to the other settings ($106, $103, and $358, respectively). Also, costs for laboratory and imaging services were lower in retail clinics than in the other settings ($15 vs. $33, $27, or $113; P<0.001).

Prescription costs per episode were similar for episodes that originated in retail clinics, physician offices, or urgent care centers ($21, $21, and $22, respectively; P>0.05) and higher for those that originated in emergency departments ($26; P=0.02 vs. retail clinics). Similar rates of antibiotic prescribing occurred across settings, allaying concerns that the retail clinics would more aggressively prescribe antibiotics.

Aggregate quality scores were similar at retail clinics, physician offices, and urgent care centers (63.6%, 61.0%, and 62.6%, respectively; P>0.05 vs. retail clinics) and lower for emergency departments (55.1%; P<0.001 vs. retail clinics). Quality of care in retail clinics, generally provided by nurse practitioners, was similar to that provided in physician offices and urgent care centers and slightly superior to that of emergency departments.

The proportions of patients who received preventive care within three months of their first visit did not vary significantly across the three care settings (retail clinics, 14.5%; physician offices, 14.2%; urgent care centers, 13.7%; P>0.05 vs. retail clinics). Fewer patients first seen at emergency departments (10.7%) received any preventive care (P=0.003 vs. retail clinics). For patients who visited a retail clinic, preventive care was typically delivered in a physician's office, suggesting that the clinics are not disrupting opportunities for preventive services.

The study authors said that patients with more severe illness would likely see their doctor or go to the emergency department, leaving retail clinics to care for simple cases. "From a societal perspective," they wrote, "it might lead to a better allocation of health care resources if more patients with a mild illness go to a retail clinic."

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IDSA releases updated immunization guidelines

The Infectious Diseases Society of America released updated clinical practice guidelines on immunization from birth through adulthood.

A panel of experts reviewed existing evidence to update the 2002 guidelines, taking into account new vaccines and new vaccine combinations that have expanded the adolescent and adult immunization schedules. The guidelines place increased emphasis on removing barriers to immunization, eliminating racial and ethnic disparities, reducing out-of-pocket costs and other financial barriers, and immunizing specific groups such as health care providers, immunocompromised patients, pregnant women, international travelers and internationally adopted children.

The complete guidelines appear in the Sept. 15 Clinical Infectious Diseases and are available online.

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Test yourself

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MKSAP Quiz: nasal mucosa with a profuse watery discharge

MKSAP QuizA 24-year-old man requests antibiotics during an evaluation for symptoms he has attributed to a sinus infection. He reports sinus congestion and clear nasal drainage that has persisted for 1 month after he developed a cold; he has no fever, sinus pain, purulent nasal drainage, sneezing, or nasal itching. Since the onset of his symptoms, he has been using a nasal decongestant spray with only short-term symptomatic relief, but he states that antibiotics have been effective in the past for treating his sinus infections. His history includes allergic rhinitis, but his primary allergens are not in season.

Nasal examination shows congested nasal mucosa with a profuse watery discharge. The nasal septum appears normal, the turbinates are pale, and there are no polyps. The remainder of the physical examination is normal.

Which of the following is the most likely reason for this patient's symptoms?

A) Allergic rhinitis
B) Bacterial sinusitis
C) Nonallergic rhinitis
D) Rhinitis medicamentosa
E) Viral upper respiratory infection

Click here or scroll to the bottom of the page for the answer and critique.

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Women's health

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Symptoms can be early indication of ovarian cancer

A significant percentage of women reported symptoms to their primary care physicians more than six months before they were diagnosed with ovarian cancer, a new study found.

The case-control study included 212 women over age 40 with primary ovarian cancer and 1,060 matched controls, all treated in general practices in Devon, England. Researchers reviewed their medical records and found seven symptoms to be associated with ovarian cancer: abdominal distension, postmenopausal bleeding, loss of appetite, increased urinary frequency, abdominal pain, rectal bleeding and abdominal bloating. The study was published online by BMJ on Aug. 25.

After researchers excluded symptoms that were reported less than 180 days before diagnosis, abdominal distension, urinary frequency and abdominal pain were independently associated with ovarian cancer. Abdominal distension was the most significant factor, with a positive predictive value of 2.5%. The researchers also looked at the factors in combination and found some to be particularly predictive. For example, 20 women in the cancer group had reported abdominal distension and loss of appetite prior to diagnosis, while no one in the control group had both those symptoms.

The findings indicate that earlier diagnosis may be possible for some women with ovarian cancer, the study authors concluded, although they noted that it's unknown whether earlier diagnosis would yield clinical benefit. Abdominal distension, in particular, is a common enough symptom to warrant rapid investigation for possibility of ovarian cancer, the researchers said. An accompanying commentary recommended pelvic ultrasonography for women who have the concerning symptoms without an obvious cause.

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Medical imaging

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CT and nuclear scans major source of radiation exposure

Medical imaging represents a major source of radiation exposure for the non-elderly U.S. population, according to a large new study of medical claims data.

Of the 952,420 adults between 18 and 64 included in the study, 68.8% underwent at least one imaging procedure that exposed them to radiation during the three-year study period. The mean cumulative effective dose was 2.4 mSv per enrollee per year. (Health care and nuclear workers are restricted to effective doses of 20 mSv per year.) However, a portion of studied patients were subjected to high (20 to 50 mSv per year) or very high (>50 mSv per year) doses: 18.6 per 1,000 people received high effective doses, and 1.9 per 1,000 had very high doses.

The study also looked at the imaging procedures that most contributed to the exposure. Myocardial perfusion imaging accounted for more than 22% of the total effective dose, and CT scans of the abdomen, pelvis and chest accounted for nearly 38%. In total, CT and nuclear imaging accounted for 75.4% of the cumulative dose. More than 70% of the recorded procedures were plain radiography, but those procedures were responsible for only 10.6% of the total effective dose.

Extrapolation of the study's findings would indicate that about 4 million non-elderly Americans are subjected to radiation doses exceeding 20 mSv per year, the authors concluded. It's particularly concerning that younger patients are being exposed to these levels of radiation, because they face a lifetime of accrued risk.

The researchers also noted that similar levels of exposure may pose greater cancer risks for women than men, and that prior studies have a shown a lack of awareness among physicians about the risks posed by CT scans. The study indicates the necessity of developing strategies for optimizing and ensuring the appropriate use of imaging procedures, the authors concluded.

The study was published in the Aug. 27 New England Journal of Medicine.

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Cardiology

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Combination therapy seems to offer no benefit over high-dose statins in high-risk patients

Adding another lipid-modifying agent to a statin does not appear to add benefit over high-dose statins alone in patients requiring intensive lipid-lowering therapy, according to a new study.

annalsResearchers performed a meta-analysis of 102 published studies to compare the benefits and risks of high-dose statin monotherapy and combination statin therapy in adults at high risk for coronary disease.

They found very low strength evidence showing that statin-ezetimibe therapy (two trials in 439 patients) and statin-fibrate therapy (one trial in 166 patients) did not reduce mortality more than high-dose statin monotherapy. No trials evaluated the effect of combination therapy versus high-dose statin monotherapy on myocardial infarction, stroke or revascularization procedures. Two statin-ezetimibe trials involving 295 patients found that those receiving combination therapy were more likely to achieve LDL cholesterol goals (odds ratio, 7.21 [95% CI, 4.30 to 12.08]). Mortality did not differ in trials involving lower-risk patients. The study results were published online Sept. 1 by Annals of Internal Medicine.

The authors acknowledged that because most of the included studies were short and focused on surrogate markers, their ability to detect potential differences in important clinical outcomes was limited. They also noted that some combinations of medications, doses and patient populations were not considered.

However, they concluded that existing evidence supporting combination therapy over monotherapy is not sufficient to guide clinical decisions. "The effectiveness of statins in reducing vascular events suggests that the benefits of additional therapies need to be clearly defined along with attendant risks and costs before advocating widespread use of combination treatment," they wrote.

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Paper summarizes latest evidence on antiplatelets and antithrombotics for ACS

A new paper examines the safety, efficacy and timing of antithrombotics in acute coronary syndromes, highlights outstanding controversies and looks at the potential roles of the most promising new drugs in late-stage development.

The analysis, published online and in the Sept. 8 Journal of the American College of Cardiology, summarizes the evidence regarding the use of antiplatelets and anticoagulants for acute coronary syndromes (ACS). Despite great advances in antithrombotic therapies, high risks remain connected with patient comorbidities, drug combinations, dosing adjustments and complex care environments, the authors said. The paper includes the following observations:

Antiplatelets

  • Data support the use of intravenous glycoprotein IIb/IIIa inhibitors (GPIs) in the setting of moderate- or high-risk non-ST-segment elevation ACS (NSTE-ACS), especially in the case of early invasive strategy. Patients presenting with ST-segment elevation myocardial infarction (STEMI) who are undergoing percutaneous coronary intervention (PCI) also may benefit. For low-risk ACS, GPIs are potentially harmful in troponin-negative patients under conservative management strategy or those with elevated bleeding risk.
  • Clopidogrel plus aspirin appears beneficial and safe in patients with STEMI, although there are no safety data with a loading dose for elderly patients receiving fibrinolytics or in patients with STEMI managed without reperfusion therapy.
  • The benefits of early pre-loading with clopidogrel within five days of surgery appear to outweigh the risks of perioperative bleeding.
  • Prasugrel has a protective effect in ACS patients and may reduce stent thrombosis, but it may increase major bleeding in patients with a history of stroke or transient ischemic attack, patients age 75 or older and those weighing less than 60 kg.

Anticoagulants

  • Low-molecular weight heparin (LMWH) has proven superior to short-term unfractionated heparin (UFH) in conservative management of patients with NSTE-ACS, but questions remain about the use of LMWHs in certain settings, including an early invasive strategy, rapid transitions to catheterization lab, procedural anticoagulation and in conjunction with fibrinolytic therapy for patients with STEMI.
  • Adding UFH to enoxaparin in an uncontrolled fashion may result in increased bleeding complications.
  • Continued in-hospital administration of enoxaparin may provide substantial additional benefit in patients with STEMI.
  • Overall, LMWH appears to be a viable option across a wide spectrum of patients presenting with ACS, suggesting that it should be investigated further for potential use in other settings such as primary PCI for acute MI.
  • The factor Xa inhibitor fondaparinux appears to reduce the risk of bleeding and lowers long-term morbidity and mortality compared with enoxaparin in NSTE-ACS, although there were more catheter-related thrombi. However, fondaparinux appears to be associated with a risk of harm (increased rate of coronary complications) in STEMI patients treated with primary PCI.
  • Promising drugs in the pipeline include novel anticoagulants that inhibit propagation of coagulation by targeting factor IXa, Xa or their cofactors. These agents are based upon aptamer technology, which addresses control and reversibility in acute care settings, which has potential to play a crucial role during and after cardiopulmonary bypass for coronary surgery and other situations where bleeding occurs. However, the authors noted that long-term investments are needed to gain clinical and regulatory acceptance of these new drugs.

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FDA update

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Liver problems reported with orlistat

Safety information for orlistat (sold under brand names Xenical and Alli) is being reviewed by the FDA after reports were received of liver-related adverse events in patients taking the drug, the agency announced last week.

Between 1999 and October 2008, 32 reports of serious liver injury, including six cases of liver failure, in patients using orlistat were submitted to the FDA's Adverse Event Reporting System. The most commonly reported adverse events were jaundice, weakness and abdominal pain. The agency cautioned that no definite association between liver injury and orlistat has been established and that the FDA is not advising health care professionals to change their prescribing practices.

Health care professionals and consumers are encouraged to report side effects from the use of orlistat to FDA's MedWatch program.

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Accusure insulin syringes recalled

Two lots of Accusure insulin syringes are being recalled by the manufacturer, according to an FDA alert. The syringes have been found to have needles that can detach from the syringe and become stuck in the insulin vial, push back into the syringe, or remain in the skin after an injection.

The syringes were distributed by Qualitest Pharmaceuticals between January 2007 and June 2008 and are labeled as Accusure Insulin Syringes 31 G–Short Needle, either 1/2 cc or 1 cc, lot number 6JCB1 or lot number 7CPT1. The lot number can be found on the white paper backing of each individual syringe. Anyone who has affected syringes should not use them and should contact Qualitest at 1-800-444-4011 for product replacement instructions.

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From ACP Internist

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The next issue of ACP Internist is online and in your mailbox

The next issue of ACP Internist is online, featuring stories on:

Guiding clinicians through GI diagnoses. ACP Internist wraps up highlights of Digestive Disease Week, including dyspepsia, weight loss and incontinence, as well as the latest about the risks of proton-pump inhibitors and antithrombotics.

MS confounds, calls for better coordinationMS confounds, calls for better coordination. Internists are closely involved in care for multiple sclerosis, from recognizing symptoms to preventing complications. As the first line of defense, primary care physicians can find reassurance in guidance from a recent consensus paper on differential diagnosis.



Mindful medicine: Unmasking the patient’s hidden agenda. Something about a response of ‘so-so’ triggers Ian Gilson, FACP, to delve further into how a patient is feeling—and a potentially suicidal hidden agenda.

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Your Thoughts Exactly: town hall meetings on health reform

In August, members of Congress and the White House held town hall meetings to discuss health care reform. The meetings were sometimes productive but often contentious. Tell us: Were the meetings more of a success or a failure in terms of making progress on the issue?

Also, Steven Weinberger, FACP, ACP Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, discusses "Health Care Reform: The Uncivil War Dividing America," in his monthly column for KevinMd.com, one of the Web's most influential medical blogs.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.


"Sir, I said follow my finger, not swallow my finger."

This issue's winning cartoon caption was submitted by Leigh Nathan, a fourth-year medical student at Temple University School of Medicine in Philadelphia, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 151 ballots online to choose the winning entry. Thanks to all who voted!

The runners up were:
"You still need to undress. I told you I wouldn't be able to feel your prostate from this end."
"This is a new treatment for excessive verbiage about health care reform."

ACP Internist's cartoon caption contest continues after the Labor Day holiday.

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MKSAP answer and critique

The correct answer is D) Rhinitis medicamentosa. This item is available online to MKSAP subscribers in the General Internal Medicine section, Item 10.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggests rhinitis medicamentosa. Repeated use of nasal decongestants causes a decreased sensitivity to their vasoconstrictor effect and a rebound phenomenon with increased nasal congestion and discharge. Management involves immediately withdrawing the vasoconstrictor and initiating treatment with a nasal corticosteroid spray. Allergic rhinitis is unlikely in this patient given his lack of allergy symptoms, such as sneezing and nasal itching, and because the symptoms are occurring when the patient's allergens are not in season. The absence of purulent drainage, fever, and sinus pain and the presence of pale turbinates argue against a diagnosis of bacterial sinusitis. Although nonallergic or vasomotor rhinitis can possibly be a complication of allergic rhinitis, environmental changes, such as air pollution, temperature or humidity changes, or nonspecific irritants, such as spicy foods, strong odors, perfume, exhaust fumes, cigarette smoke, and solvents, usually precipitate vasomotor symptoms. Most viral upper respiratory infections resolve within 1 week; long-term symptoms usually indicate a secondary bacterial infection.

Key Point

  • Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggest rhinitis medicamentosa.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2009 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

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